mHealth involves using wireless technologies such as Bluetooth, GSM/GPRS/3G, WiFi, WiMAX, storage devices, and so on to transmit and enable various eHealth data contents and services. Usually these are accessed by the health worker through devices such as mobile phones, smart phones, PDAs, laptops and tablet PCs.

Project Chronology

When was HealthPhone™ conceived?

October 2009. Our work with local and state governments, UNOs and NGOs over 2005 — 2009 led us to initiate the HealthPhone™ project.

Ground work to define the content to develop, selection of audience and languages, the way to show content in order to assist in behaviour modification, amongst other aspects of the project has been continuing during this period.

When was HealthPhone™ announced?

October 2010.

What is the project completion date?

We aim to reach 20,000 villages in India by early 2015. Evaluation of the programme will help to identify next steps in terms of further scaling up across India and beyond. In the meantime, we will continue to explore opportunities for pilots in other countries. This is a long-term, ongoing programme. We aim to commit to at least 10 years of effort to be able to ensure that the concept takes root and is sustainable in a number of countries.

Background

What was the background and the motivation behind developing HealthPhone™?

The First Mile Now ReachableSeveral surveys conducted over the past decade have highlighted the importance and direct link between health knowledge and mortality rates of infants and women.

The Internet is increasingly being used to build this capacity and reach new places. But the internet requires access: to an Internet connection, a telephone line, a computer and electricity. And, most importantly, it requires the ability to read.

Without an Internet connection and a telephone line you can access information on a computer’s removable hard drive, CDs, DVDs, etc; and without a computer you can access information on radio and television. But neither computer, nor TV nor radio are of relevance if you can’t afford them.

If you don’t have electricity, you may still have access to newspapers and other printed materials — but they are not much use unless you are literate.

And this still leaves the illiterate, the most vulnerable person, with little or no access to health knowledge.

Audience

What is your geographical and socioeconomic scope? Who is the target audience/end user for HealthPhone™?

Initially, HealthPhone™ will serve people in more than 20,000 rural Indian villages. The content being in 15 Indian languages makes it possible for a large percentage of the population, from different parts of India, to be reached.

The health workers are part of the delivery mechanism, part of the way to get HealthPhone™ into the hands of village women.

After HealthPhone™ has been established in India, it is our plan to take it worldwide.

In the long term, HealthPhone™ can serve everyone, everywhere; but is of greatest application for individuals, families and health workers in rural and urban slums. The focus is on reaching the illiterate community since all other health materials currently available only in print are not useful to them. The health and well-being of hundreds of millions of people would be impacted by effective use of HealthPhone™.

Is HealthPhone™ illiterate friendly?

HealthPhone™ is aimed at those most requiring health knowledge; especially the illiterate.

Illiterate friendly — menus and health messages are spoken, in addition to being shown as text on the screen. This helps in association of the spoken and written word, which is a step towards literacy.

Why do you focus on delivering health knowledge to mothers and young women?

According to a recent analysis published in The Lancet, half the reduction in child mortality over the past 40 years can be directly attributed to better education for women. If a woman knows better how to care for her child she will demand more, so strengthening her ability to care.

For every one-year increase in the average education of reproductive-age women, a country experienced a 9.5 percent decrease in child deaths.

A mother's education affects her children's health in myriad ways, said Christopher J.L. Murray, a co-author of the study.

According to Murray, better-educated women are more likely to understand disease-prevention measures such as vaccines and mosquito nets and to use them. They are more likely to take a sick child to a clinic early. They more probably understand germ theory and how to set clean water and sanitation as household priorities.

Improving education tends to increase national wealth, which in turn improves population's health. But the new study shows that improving education directly reduces child mortality — and more effectively than increasing gross domestic product.

Mothers are often referred to as the family’s Chief Health Officer, and are increasingly using mobile phones to manage and track their family’s health and wellness information.

A recent study showed that mothers index higher than the general population in most categories when it comes to mobile phone activities, and health was no exception.

One in three mothers used her mobile phone for health purposes, compared to 22% of the general population. Further, the study conveyed that nine out of 10 mothers who own smartphones used the devices to research health conditions.

Women are not only more comfortable with technology than they were a year ago and are embracing mobile phones for a variety of activities, but are also more active than men in using medical and health-related phone applications.

HealthPhone™ aims to save the lives of children and their mothers. It seeks to do so by educating people and so inspiring changes in behaviour, specifically the taking of preventative steps towards reducing the impact of preventable diseases.

• The largest population among illiterates are women — so anything on mobile phones, perennially impacts and empowers women.

• Mobile phones are now being considered by the Government of India as the main tool to empower citizens, especially those who have been excluded.

• 300 million mobile phone users in India are women — certainly the largest to be targeted to ride many empowering services.

• Mobile phones have been adopted by Eko, State Bank of India, Hand in Hand, Barefoot College, CGNet to empower women at large for financial inclusion, banking, citizen journalism, education and so on.

• Government of Bihar has enabled Right to Information Act with IVR system to lodge RTI application orally — thus has empowered not only rural poor but mainly women.

• Government’s largest program called MNREGA (Mahatma Gandhi National Rural Employment Guarantee Act) has adopted mobile phones to disburse money to control corruption at the bottom of the pyramid.

Do you think mobile technology and applications have to be more inclusive to serve specific communities and undeveloped regions?

Yes and No.

Yes, because specific communities and undeveloped regions have very specific needs. Additionally, their literacy level is also quite different from those in more developed regions. Their access to health workers, doctors, hospitals and other facilities is also substantially different.

No, because basic health knowledge is required by people no matter where they live and is fundamentally the same for each human being.

But can mHealth apps really work for the poor? How?

We believe the answer is yes they can, but they need to be more responsive to the needs of poor users.

• Hundreds of millions of poor people own a mobile phone. There are over 50 mobile phones for every 100 adults in almost all of the eleven countries (Bangladesh, China, Congo, Ethiopia, India, Indonesia, Nigeria, Pakistan, Philippines, Tanzania and Viet Nam) those together accounts for over 2 billion people living on less than US$2 per day. In comparison, the number of Internet users in low-income countries worldwide remains below 3%.

• Poor households already rely on apps such as mobile banking in many countries. Mobile banking for saving and transferring remittances is already used by millions. In India, service is available in 3 of the largest cities, Delhi, Bangalore and Chennai. In Kenya, 12 million people use the text-based mobile banking app M-Pesa. There are entire apps stores dedicated to serving the needs of developing country users. For example in India, Aircel, Airtel, Vodafone, Idea Cellular, Reliance, and Virgin all recently opened apps stores.

• Apps have a high added value for previously unconnected people. For people who lack other means to access information such as health centres, libraries, TV or the Internet, mobile apps are particularly useful because they can be accessed offline (i.e. without using expensive phone credit) from anywhere with a single battery charge. Users in Congo, Indonesia and many more countries are skipping the personal computer experience altogether and accessing parts of the Internet for the first time through their mobile phones. For example, the Facebook app comes preloaded on many handsets and lets users communicate with other Facebook members worldwide. What is more, sending and receiving messages through this app is currently free because the data charges are absorbed by Facebook and the mobile carriers.

• The demand for health information is very strong in countries suffering from a scarcity of doctors and health workers. Innovative apps can help maximize the use of scarce healthcare resources available in a country to help as many people as possible.

In a nutshell, mHealth apps can serve the poor because the necessary technology is already available and used by poor people, and because demand for health related information is very significant.

Content

Is the content mainly with US/European end-users in mind or is it appropriate for end-users in rural Africa/Asia?

Our videos provide vital messages and information for mothers, fathers, other family members and caregivers and communities to use in changing behaviours and practices that can save and protect the lives of children and help them grow and develop to their full potential. These messages apply to people everywhere in the world. The content is in an easy-to-understand language.

We plan to develop content more specific for other cultures and languages in the future.

What content do we deliver?

HealthPhone™ uses communication processes to improve life chances for poor and vulnerable populations. A mobile phone, with basic health information embedded on the phone, will provide families in rural villages and slums with essential health information, in their hands, when they need it, in a language they understand and with visual information that works for those with low literacy levels.

We plan to "teach" not "preach". Knowledge will be provided in the form of ‘how to’ video and audio messages covering basic health and nutrition areas.

HealthPhone™’s reference library consists of video, audio and image files highlighting over 125 key health messages and tips in English and (initially) 15 Indian languages.

Who developed the materials? Have they been properly validated, and is there a possibility of commercial bias? Is the content accurate, relevant and reliable?

The health knowledge on HealthPhone™ is scripted on the Facts for Life publication, a trusted resource developed by 8 UN organizations: United Nations Children's Fund (UNICEF), World Health Organization (WHO), United Nations Educational, Scientific and Cultural Organization (UNESCO), United Nations Population Fund (UNFPA), United Nations Development Programme (UNDP), Joint United Nations Programme on HIV/AIDS (UNAIDS), World Food Programme (UNFP), The World Bank.

It contains what every health worker, family and community has a right to know about 14 key health areas.

Material from Facts for Life has been used in radio and television programmes, newspaper and magazine supplements, distributed as pamphlets and audio cassettes, incorporated into school textbooks and adapted for comic strips, soap operas and theatre groups. While the material by itself is no substitute for the medicines and basic equipment so desperately needed in many countries, for the world's poorest, who have so few other ways of finding things out, the Facts for Life information and advice have proved themselves to be life-savers.

Here are some examples taken from Facts for Life.

Many parents do not know that breast milk is the only nourishment an infant needs in the first six months. Some 1.5 million children might be saved each year if they were not also given polluted water.

Many people believe that drinking liquids makes diarrhoea worse, when someone suffering from it should actually drink as much liquid as possible.

It is safe to immunise a child who has a minor illness or disability, or who is malnourished. Many parents, and even health workers, do not know this.

The symptoms of pneumonia are often overlooked, with fatal results.

Staunching a cut with mud, a traditional remedy, often causes infections.

Facts for Life is designed with input from poor people themselves, to make sure it answers their most urgent questions.

Why is health knowledge important to save lives?

Health knowledge is one of the most effective ways to reduce maternal and child mortality, those preventable deaths that we never seem to manage to prevent. We need to deliver vital messages and information for mothers, fathers, siblings, caregivers and communities to use in changing behaviour and practices: messages that can save and protect the lives of children and help them grow and develop to their full potential.

With education, a girl gets married later, has fewer children and times the birth of her children to protect her health and that of her child. This has been shown to be the case with women who received health education in their teens or earlier in Zambia, Uganda, Nepal, Pakistan, Brazil, Bangladesh, and many other countries. And it’s clear that when children live a full healthy life, their parents have fewer children. There’s a shift from quantity of death to quality of life.

Why use the mobile phone to deliver health education?

The mobile phone has made connection possible in ways that were truly unthinkable until very recently. This means we can reach the excluded, the illiterate, all those women, men and children who were only visible in tragic statistics. We can reach families and communities as a whole — something we've never really been able to do before. The mobile phone has tremendous, and far-reaching and affordable, life-saving potential.

How does HealthPhone™ provide interactivity and ease of use to the users?

A feedback option at the end of every video message creates a SMS text message sent for content evaluation, additions and improvements.

With the content being pre-loaded, embedded or on removable media, the product becomes extremely easy, quick and desirable to use, with:

• No signal is required
• No connection is required
• Nothing to download and install
• Content available from anywhere
• Programme accessible from icon on mobile desktop
• Very intuitive menus and navigation methods; and
• GPS able to set default language based on location

Pilot Programmes

When and where are pilot programmes being conducted?

Initial pilot projects were conducted in Maharashtra, India. We are discussing, on an on-going basis, partnerships and collaborations with several governments and NGOs.

What was the language and content of the HealthPhone™ pilot programmes?

For the pilot programmes, HealthPhone™ included video messages in Hindi promoting:

1. Routine Immunization — raise awareness and explain benefits.

2. Zinc and ORS — management of acute diarrhoea to reduce the incidence by generating community demand; key hygiene and sanitation behaviours — use of toilets.

4. Early and Exclusive breastfeeding during the first 6 months of life.

What is the roll-out plan after the pilot programmes?

The scope of the pilot programmes includes a substantial focus on village women. ASHAs and Women Self Help Groups will be assisted and monitored and their evaluations will greatly influence the final roll-out plan. We are currently integrating and packaging HealthPhone™ with other mobile health efforts so that we can rapidly achieve wide distribution; especially towards getting it into the hands of village women.

Once the video content has been produced, there is little additional cost in scaling up. i.e. about US$2 per health worker or villager for the videos on a microSD card.

What else is happenning after the pilot programmes?

After we put HealthPhone™ into the hands of village women, not only is their health and the health of their children dramatically improving, but they now have a communication tool that opens up their world — better education, livelihood opportunities, trade and better pricing for the goods they sell — and so on. And others can reach, share and teach these women with their own free downloads — agricultural advice, how to build low-cost housing, education highlights, democracy and accountability processes — and so on.

What feedback, comments, and user experience have you received so far?

A two day visit to the village of Sauna in Uttar Pradesh to test the prototype was conducted in March 2011. Feedback from ASHA, ANM, Anganwadi and other health workers, village heads, teachers and students, and others was very positive.

We learned a lot about how they wanted to and would use HealthPhone™ and questions such as these were raised: Who should use it?, What content should be on it?, How they learn?, What phones do they have access to at home at the moment?, How many calls they make daily?, How they use the mobile?, How they load music on their phone?, How much they feel connected?, How much more they want?. It was apparent that they are truly willing to participate in this project because it gives them more control of their families’ lives.

All their input was taken into consideration for field testing and pilot programmes.

What limitations and challenges has HealthPhone™ faced while working on design, implementation, running and sustainability?

Initially the limitation was on the type of handsets that were being used by the masses. Now we are finding that local and state governments and NGOs working in the field are upgrading their phones to those that have video capability.

As the prices of these ‘semi-smartphones’ drop, and the features and functions of 'feature phones' increase, we are seeing more and more people owning them. We expect this trend to continue. Also, having content available to view on such phones is a reason and an encouragement to acquire such phones.

Content is being revised to suit local habits and cultural thinking. We are also adapting content so that it initiates and supports behaviour change.

User interface is being modified based on input from initial users. We expect to do further work in this area.

Impact

What impact do you envision that HealthPhone™ will have in diverse locations and people?

According to a recent analysis published in The Lancet, half the reduction in child mortality over the past 40 years can be directly attributed to better education for women. If a woman knows better how to care for her child she will demand more, so strengthening her ability to care.

For every one-year increase in the average education of reproductive-age women, a country experienced a 9.5 percent decrease in child deaths.

A mother's education affects her children's health in myriad ways, said Christopher J.L. Murray, a co-author of the study.

According to Murray, better-educated women are more likely to understand disease-prevention measures such as vaccines and mosquito nets and to use them. They are more likely to take a sick child to a clinic early. They more probably understand germ theory and how to set clean water and sanitation as household priorities.

Improving education tends to increase national wealth, which in turn improves population's health. But the new study shows that improving education directly reduces child mortality — and more effectively than increasing gross domestic product.

HealthPhone™ aims to save the lives of children and their mothers. It seeks to do so by educating people and so inspiring changes in behaviour, specifically the taking of preventative steps towards reducing the impact of preventable diseases.

Building Capacity and Scaling up

How do you plan to get HealthPhone™ into people’s hands?

Several adoption scenarios are being defined to start with and there will be others as we get further down the road.

In the Tonk District in Rajasthan, we will work with GoI, UNICEF and the State Government in training 800 ASHA and other health care workers in the use of HealthPhone™. Each of these health care workers serves a population of 1,000 villagers.

In Uttar Pradesh and Bihar, we will work with UNICEF, as part of its programme on child health, to train village leaders and community mobilisers to use the phone for targeted social mobilization and communication as a component of the 107 block plan for polio eradication in UP and Bihar.

In Jharkhand, we will work with UNICEF to use HealthPhone™ to stimulate focus group discussions. UNICEF supports 75 Women Self Help Groups who are active in health and community development.

How scalable is it?

The project is very scalable. The content will initially be in the major languages of India. It will be available for free. It will be pre-loaded, embedded, on removable media and downloadable.

The major expense is in content development. There is also a cost associated with designing and developing delivery. Funding the research and development of new content and more effective delivery methods is our on-going task.

If a picture is worth a thousand words, then a video is worth a million.

Videos and mobile phones have been proven to be effective tools for health education in general.

The major strength of moving image media is that they are very close to human perception and thus easy to comprehend by audiences with a wide range of cultural and educational backgrounds, which explains their widespread and broad acceptance across the globe. The visual character makes film the preferred medium for demonstrating and explaining technical and practical aspects of real-world scenarios. Furthermore, digitalization has led to a massive and still ongoing minimization of production and distribution costs.

Especially in developing countries, new forms of digital media distribution are increasing and in a lot of places allow access to video-based educational material for the first time.

Other Uses of Content

How else will the video, audio and text content be used?

For those with mobile phones without video capability — sms/text only
• The key messages, in regional languages, would be sent as text messages.

For those with Internet access and who can afford it
• We plan to make all our content downloadable from app stores, app markets, YouTube, How-to and other video libraries for wider distribution.

We will encourage key media outlets — both TV and radio — to make use of the content and incorporate it into their regular programming schedules as a means of both spreading access to the content and knowledge about where to get access to a HealthPhone™.

• All the content will be available for free download in formats suitable for a variety of other players — iPods, iPads, PDAs,...

• We aim to provide the ability to select specific content and install it as an app on Symbian, Android, Windows Mobile, iPhone and other popular mobile platforms.

For the illiterate
• The audio content, in all languages, will be available for download for use by conventional and community radio stations.

• Broadcast of messages on TV.

• Enhance the current knowledge by facilitating lectures and training courses which will allow for dialogue and interaction of hundreds of people simultaneously. Key health issues will be taught and discussed by doctors, medical specialists, medical students, and health care providers at the existing virtual learning centres in India with video conferencing facilities linked by satellite.

This programme looks to utilize EDUSAT, an exclusive satellite for educational purposes, that is presently in a geo-stationary orbit. The initial establishment of ground infrastructure and the software needed for the distance education programmes is well under way. EDUSAT meets the needs of a growing demand for an interactive satellite based distance education system for the country.

The new areas which need special attention include linking of schools, colleges/universities, educational institutions, continuing education and up-gradation of professionals (e.g. doctors, lawyers, etc.). The thrust will be on reaching people in remote areas and facilitating interaction between them and other academics and health professionals.

Other satellite feeds will be used as and when they become available for direct broadcasting of videos with health knowledge.

For those without Internet access
• CDs and DVDs of the content would be available for duplication and distribution.

For those who own a tablet PC
• Our content and delivery mechanisms are compatible and can be used on these devices.

For those without a computer
• All content in all languages will be available for handouts which can be easily re-printed, copied and distributed.

Affordability

Can they afford to buy a mobile phone?

Increasingly, the answer to this question is “yes”. Falling costs of domestic and imported handsets are driving this shift even faster. Phones with Internet browsing capability already sell for less than US$20. We will work with local phone manufacturers and connectivity distributors to broker even lower cost options. We will also work with international, national and local development organisations to encourage bulk purchase and subsidisation of phones for villagers as part of their ongoing development programmes.

Can they afford to download content?

All of HealthPhone™’s content will be available for free download to people's current phones.

We are also working with handset manufacturers to make our content available by preloading on every mobile handset. A medical emergency is not the time to download an app — the information should be there in advance for when it is needed.

Commercial Model

What is the commercial model for HealthPhone™?

HealthPhone™ is primarily a not-for-profit project. Specifically, it is committed to being available free of charge to those who cannot afford to pay. Its aim is to make basic health knowledge more easily available to health workers, families and communities all over the world. It is important that the end-user, in developing countries does not have to pay for access to this information. It has to be freely available.

The delivery platforms, mechanisms, networks, partnerships created and lessons learned could very well serve to facilitate the broadcasting of non-health-related knowledge as a social enterprise, i.e. with a commercial component to help support the primary objective of knowledge distribution.

Most uses of mobile technology in the health field to date have been limited to supplier-determined usages. The HealthPhone™ aims to put the end user in control of when and where to access the content — particularly to have key life-saving information on tap, in a local language and in a format that is understandable in circumstances of low-literacy. It is designed to empower.

Why is HealthPhone™ considered innovative?

Innovative Idea

• HealthPhone™ is an in-depth reference library of the main health issues that cause child and maternal mortality. Other offerings are mostly about one particular disease or message.

• The mobile phone is relatively new and new business models are being created. We are working with all stakeholders to develop structures and partnerships; handset manufacturers, service providers, government health, education and telecommunication departments, UNOs, NGOs and others and creating ways to work together in the delivery of this knowledge using mobile phones.

Innovative Technology

• Content delivery systems for a variety of handset platforms and models

For the first few years, the project will need the support of capital and other resources. We look to it being sustainable on its own by adopting a model and structure that will produce revenues that allow us to maintain and grow HealthPhone™ and its offerings and services.

We are working with governments, UNOs, NGOs, Corporate Social Responsibility personnel, investors, and others to fund this project.

A key outcome of the first three years of the pilot activity will be the development of a strong and sustainable business model that we expect will attract sufficient investment and will provide regular inflows of capital.

General

How do we break the chain of the 'road to death', whereby a chain of events, decisions and circumstances lead to most, if not all, avoidable deaths?

That chain could be broken by empowering parents and healthcare providers, including empowerment with basic clinical healthcare knowledge such as recognition of danger signs.

Social autopsy: The sequence of circumstances, events, decisions and other contributing factors in the hours, days and weeks preceding the avoidable death of a child, woman or man. A better understanding of social, economic, environmental and health knowledge factors is vitally important. It has been described in one recent paper as 'a powerful tool with the demonstrated ability to raise awareness, provide evidence in the form of actionable data and increase motivation at all levels to take appropriate and effective actions'.

What is your vision of “A global network of people using mobile technology for reaching masses”? How do you think mobile technology can be used towards reaching masses through meaningful mobile health applications/content/services?

By sharing knowledge.

We need to consider the present circumstances, learn from best practices and tradition, and avoid reinventing knowledge.

Too many sparse and valuable resources and development dollars are spent on reinventing.

Sharing programmes and resources allows people to move quickly in creating change.

What recommendations can you give to the policy-makers and industry so that mobile applications better serve people’s health needs?

We live a world in which the development and adoption of cellular telephone technology and infrastructures have rapidly overtaken the provision of basic health-promoting services such as electricity, piped water and sewerage in the poorest communities.

Many people without basic domestic services own and use cellular telephones.

To reach the masses with meaningful mobile applications, content and services we need to make them freely available at anytime and anywhere.

Handset manufacturers need to include basic health information on every phone, just as they do with games. Health information should be embedded as a default on all handsets.

It would be most helpful for government departments to encourage and include in policy documents the use of health educational tools, such as HealthPhone™, for the benefit of marginalised sections of society. Wider and quicker adoption of such tools by the government would also go a long way towards meeting humanity’s health goals.

Is it not time for governments in developing countries, as the licensing authorities for cellular telephone networks, to insist that multinational telecommunication companies exercise social responsibility by providing pro bono telecommunications services for health, nutrition and medical advice and assistance?

HealthPhone™ is truly a creative empowerment tool that can make 'health for all' a practical reality for anyone, anywhere, anytime.